Nursing health assessment: It's Purpose, Types, and Sources

1. Health Assessment:
An Introduction
Maria Carmela L. Domocmat, RN, MSN
Instructor, Nursing Health Assessment
School of Nursing
Northern Luzon Adventist College

2. Assessment: An Introduction
• Purpose
• Types
• Sources
Maria Carmela L. Domocmat, RN, MSN

3. Who among you looked at yourself in the mirror before going to class today?
WE ALWAYS PRACTICE
ASSESSMENT IN OUR DAILY
LIVING

4. WHAT CAN YOU SAY ABOUT
THESE PICTURES? WHAT
INFERENCE CAN YOU MAKE?

5. Assessment
• the collection of data about an individual’s
health state
• first and most critical phase of the nursing
process
Maria Carmela L. Domocmat, RN, MSN

6. Assessment
• ongoing and continuous throughout all the
phases of the nursing process
• is systematic and continuous collection,
validation and communication of client data as
compared to what is standard/norm
Maria Carmela L. Domocmat, RN, MSN

7. Purpose:
To establish a data base (all the information about
the client) to determine the client’s overall level of
functioning in order to make a professional clinical
judgment
To supplement, confirm, or question data obtained
in the nursing history
To obtain data that will help the nurse establish
nursing diagnoses and plan patient care
Maria Carmela L. Domocmat, RN, MSN

8. To evaluate the appropriateness of the nursing
interventions in resolving the patient's identified
pathophysiology problems
collect data of patient’s health status, to identify
deviations from normal, to discover the patient’s
strengths and coping resources, to point actual
problems, and factors that place the patient at risk
for health problems
Maria Carmela L. Domocmat, RN, MSN

9. • Wholistic data collection.
• Nurse collects physiologic, psychological,
sociocultural, developmental, and spiritual data
about the client
Maria Carmela L. Domocmat, RN, MSN

10. nurse focuses on how client’s health status
affects his activities of daily living (ADL) and
how the client’s ADL affect is health
Ex: client with asthma
Maria Carmela L. Domocmat, RN, MSN

11. assess how client interact within their family,
cultures, and community and how the client’s
health status affects the family and community
Ex: client with DM who has amputation; single
parent mother of a 6 year-old child
Maria Carmela L. Domocmat, RN, MSN

12. • Data from nursing assessment can be
classified as subjective and objective.
Maria Carmela L. Domocmat, RN, MSN

13. Data include:
nursing health history
physical assessment
the physician’s history & physical
examination
results of laboratory & diagnostic tests
material from other health personnel
Maria Carmela L. Domocmat, RN, MSN

14. Performing assessment is like
collecting the pieces of a puzzle

15. Assessment
– The first step in determining the health status of the
client
– Because the entire plan of care is based on the data
collected during this phase, you need to make every
effort to ensure that your information is correct,
complete, and organized in a way that helps you
begin to get a sense of patterns of health or illness.
Maria Carmela L. Domocmat, RN, MSN

16. Types of Assessment
Maria Carmela L. Domocmat, RN, MSN

17. Types of Assessment
• Initial comprehensive assessment
• Ongoing or partial assessment
• Focused or problem-oriented assessment
• Emergency assessment
• Time-lapsed assessment
Maria Carmela L. Domocmat, RN, MSN

18. Initial comprehensive assessment
• assessment performed within a specified time on
admission
Maria Carmela L. Domocmat, RN, MSN

19. Initial comprehensive assessment
• Involves collection of subjective data about the
– client’s perception of his/her health of all body parts or
systems,
– past health history,
– family history, and
– lifestyle and health practices (which includes information
related to the client’s overall function) as well as objective
data gathered during a step-by-step physical examination
Maria Carmela L. Domocmat, RN, MSN

20. Initial comprehensive assessment
When performed?
• On the initial contact with the client
• where: hospital, community, clinic or home
setting
• purpose: to have a baseline comprehensive data
about the client
• Ex: nursing admission assessment
Maria Carmela L. Domocmat, RN, MSN

21. Ongoing or partial assessment
Maria Carmela L. Domocmat, RN, MSN

22. Ongoing or partial assessment
• consists of data collection that occurs after the
comprehensive database is established
• consists of mini-overview of the client’s body
systems and holistic health patterns as a follow-
up on his health status
Maria Carmela L. Domocmat, RN, MSN

23. Ongoing or partial assessment
• When performed?
• usually performed whenever the nurse or
another health care professional has an
encounter with the client
Maria Carmela L. Domocmat, RN, MSN

24. Ongoing or partial assessment
• purposes:
• Any problems that were initially detected in the
client’s body system or holistic health patterns
are reassessed in less depth to determine any
major changes (deterioration or improvement)
from the baseline data.
• Brief reassessment of the client’s normal body
system or wholistic health patterns is performed
to detect new problems
Maria Carmela L. Domocmat, RN, MSN

25. Focused or problem-oriented assessment
• consists of a thorough assessment of a particular
health problem and does not cover areas not
related to the problem
• purpose: to have a thorough assessment on the
special health concern of the client identified in
an earlier assessment
Maria Carmela L. Domocmat, RN, MSN

26. Focused or problem-oriented assessment
• When performed?
• performed when a comprehensive database
exists for a client and he/she comes to the
health care agency with a special health concern
Maria Carmela L. Domocmat, RN, MSN

27. Emergency assessment
• a very rapid assessment performed in a life-
threatening situations
• rapid assessment done during any
physiologic/physiologic crisis of the client to
identify life threatening problems
Maria Carmela L. Domocmat, RN, MSN

28. Emergency assessment
• purpose: to determine the status of the client’s
life-sustaining physical functions
Maria Carmela L. Domocmat, RN, MSN

29. Time-lapsed assessment
• reassessment of client’s functional health pattern
done several months after initial assessment to
compare the client’s current status to baseline
data previously obtained.
Maria Carmela L. Domocmat, RN, MSN

30. Sources of Data
Maria Carmela L. Domocmat, RN, MSN

31. Sources of Data
• Primary source:
• Secondary source:
Maria Carmela L. Domocmat, RN, MSN

32. Sources of Data
• Primary source:
– data directly gathered from the client using
interview and physical examination.
Maria Carmela L. Domocmat, RN, MSN

33. Sources of Data
• Secondary source:
– data gathered from client’s family members,
significant others, client’s medical
records/chart, other members of health team,
and related care literature/journals.
Maria Carmela L. Domocmat, RN, MSN

34. Maria Carmela L. Domocmat, RN, MSN